A commentary on ‘robotic pancreaticoduodenectomy in elderly and younger patients: a retrospective cohort study’ [Int J Surg. 81 (2020) 61–5]
Authors: Henghai Yu, Xiaoping Wei
Journal: International Journal of Surgery (2023)

Dear Editor, With great interest, we read the article by Liu et al.1 who performed a retrospective cohort study to compare the safety and feasibility of robotic pancreaticoduodenectomy (PD) in elderly and younger patients. They concluded that robotic PD was safe and feasible in elderly patients and suggested that elderly patients with careful patient selection should be considered for robotic PD. Here are some queries we have for the authors. First, no new adjuvant therapies such as chemotherapy, radiotherapy, or postoperative adjuvant are found in the excluded criteria for the patients with malignant tumors especially for borderline-resectable or locally advanced pancreatic ductal adenocarcinoma, while we find pancreatic ductal adenocarcinoma accounts for the commonest indication in the two groups in the article (35.1% in the elder group, 30.2% in the younger group). Selection of new adjuvant therapy exhibited fewer postoperative pancreatic fistula and postoperative hemorrhage but increased incidence of delayed gastric emptying compared with patients treated with upfront surgery2. To some extent, the accuracy of the results, particularly postoperative complications, was impacted by the absence of this component. Second, we noticed that the preoperative jaundice rate was 71.4 and 62.4% in the elderly and younger groups of patients, respectively. In recent years, there has always been discussion on whether preoperative biliary draining (PBD) should be carried out prior to PD. Gong3 revealed that the morbidity, postoperative pancreatic fistula, and infection rate in patients with PBD were significantly higher than those in patients without it. Other surgeons suggested performing PBD in patients with malignant biliary obstruction before PD, and they found PBD did not affect the incidence of postoperative complications nor did it affect postoperative survival4. These articles demonstrate that PBD has a considerable effect on postoperative complications and patient survival, but we were unable to locate any pertinent information within this study. Finally, resections of the portal vein or superior mesenteric vein with PD were performed in some cases in this study, but we did not find any data about them in the results and discussion sections. More and more centers are performing PD with vein resection, but there are still different opinions about the technique. Some studies showed higher rates of complications such as biliary fistula, delayed gastric emptying, cardiopulmonary abnormalities, hemorrhage, 30-day mortality in the group of vein resection5. Others demonstrated no significant difference in perioperative risk between PD and PD with vein resection6. Without this part, will the reliability and integrity of the results be comprised? Further reasonable concerns should be taken into account for next-step utility. Ethical approval It is not necessary. Sources of funding Basic research projects in Yunnan Province (joint special project of Science and Technology Department-Kunming Medical University). Author contribution All authors equally contributed to the analysis and writing of the manuscript. Conflicts of interest disclosure None. Guarantor Xiaoping Wei, MD-PhD, Department of HPB Surgery, The Second Affiliated Hospital of Kunming Medical University, E-mail: [email protected].